health care organization introduction to health care organization - for medical students - ty...

Introduction to Health Care OrganizationHealth Care Organization

- for Medical Students -

Ty Borders, Ph.D.Assistant Professor

Department of Health Services Research & Management

School of Medicine / Texas Tech Health Sciences Center

Objectives for today

• Define health and disease

• Define health-related quality of life

• Evaluate the population health of the U.S.

• Compare the health of the U.S. to other nations

• Describe the impact of medical care on health

• Describe the impact of social, economic, and other factors on health

What is health?

• A simple definition– The presence or absence of disease

• WHO definition – “complete physical, mental, and social

well-being, and not merely the absence of disease or injury”

What are disease and illness?

• Disease– Professionally defined

– Precise

– Used for treatment

• Illness– Lay definition

– Individual’s reaction to biological state

– Influenced by culture

A broader definition of health:Health-Related Quality of Life

• Health-related quality of life (HRQL) encompasses those aspects of life that are dominated or significantly influenced by personal health or activities performed to maintain health.

Core concepts and domains of HRQL

• Health perceptions – General health perceptions – Satisfaction with health

• Functional status– Social function– Psychological function– Physical function

Core concepts and domains of HRQL (cont.)

• Impairment– Symptoms/subjective complaints

– Signs (observable evidence of abnormality)

– Diagnoses (clinical judgments)

• Death and duration of life

• Opportunity– Resilience; social or cultural disadvantage

How do we measure health?

• Population-level indicators– Mortality rates– Years of potential life lost– Life expectancy– Infant mortality rates– Morbidity rates– Disability rates

How do we measure health (cont.)?

• Individual-level indicators– Presence/absence of disease– Disability– General HRQL measures

• SF-36

• Sickness Impact Profile

– Disease specific HRQL measures– Psychiatric functioning measures

How healthy are we in the U.S.?

• U.S. ranks 18th with 79.1 expected years of life for a female – (# 1 is Japan with 83.0 years of life)

• U.S. ranks 23rd with 72.3 expected years of life for a male – (#1 is Japan with 76.3 years of life)

From Kindig, D.A. (1997). Purchasing Population Health.

From Kindig, 1997

Multiple determinants of health

From Kindig, 1997

From Kindig, 1997

Intro. to Health Care Organization Ty Borders, Ph.D.

14

Why do we concentrate on medical care?

• Developing societies focus on health care to improve

health

• We assume that spending more on health care will

lead to health improvements

• Increases in health services may actually reduce

population health

• Health care is reactive

– Concerned with negative health status

– Poor health professionally defined as disease

From Kindig, 1997


16

Medical care and health

• Does medical care make a difference? – For some individuals = yes

– For society at large = yes, but not too much

• McKinlay has argued that the effect of medical care on mortality

is extremely small at the population level

• About 10% of population health status attributable to medical care

• McKeown and others have argued that medical care may do more harm than good


• McKeown has shown through historical evidence that gains in life expectancy have been because of

– better nutrition, sanitation, and water supplies

– these had a much bigger impact on health than even immunizations and penicillin


A society that spends so much on health care that it

cannot or will not spend adequately on other health

enhancing activities may actually be reducing the

health of its population

Evans and Stoddart, 1990

From Kindig, 1997

What about other countries?

0

500

1000

1500

2000

2500

3000

3500

US Can Germ Jap UK

$ per capita

19851993

From Kindig, 1997


23

Rankings of health system attainment

Member state Overall system Health exp. Level of Health Performance per capitaFrance 1 4 4Italy 2 11 3San Marino 3 21 5Japan 10 13 9United Kingdom 18 26 24Canada 30 10 35Dominica 35 70 59Costa Rica 36 50 25USA 37 1 72

(World Health Organization, 2000)

From Kindig, 1997

Why does it cost so much?

From Kindig, 1997

Other reasons for increasing expenditures

• Physician income and supply– Canadians receive more services, but

expenditures are lower (physician salaries tend to be lower)

– Excess of specialists, not enough primary care providers

– Too many physicians in general

Other reasons for increasing expenditures

• Aging population

• New technology

• High rates of unnecessary utilization

• Market failure!


29

Global deaths attributable to risk factors

• Malnutrition 11.0% • Poor water supply 5.3%• Air pollution 1.1%• Tobacco 6.0%• Alcohol 1.5%• Occupation 2.2%• Hypertension 5.8%• Physical inactivity 3.9%• Illicit drugs 0.2%• Unsafe sex 2.2%• Other causes 60.1%


30

Medical care and disease

• Inequities in access, but these are not

necessarily because of inequalities in health

(Machenbach, 1999)

• Inequalities in the onset of disease, which is

not a medical care issue

Economic development and IMR

• For 36 lower and middle income countries– doubling public sector spending on health

care as a share of GNP associated with a 20 percent improvement in infant mortality (Borders and Hilsenrath, 1996)

– per capita income and literacy have greater impacts on infant mortality

Economic dev. and life expectancy

• Public health spending as a percentage of GNP has a weaker relationship with life expectancy. – doubling of public health spending as a

percentage of GNP associated with only a 7 percent increase

– per capita income and literacy have greater impacts

Economic development and health

• Decreasing marginal returns associated with per capita income

• The first $5,000 in per capita income associated with about 72 years of life expectancy

• Second $5,000 in per capita income associated with only about 3 years of life expectancy (from 72 to 75)

From Kindig, 1997

Economic development and health

• In summary, economic development has a strong impact on health

• Economic development is associated with better housing, nutrition, sanitation, and education

• So, what else determines health?

From Kindig, 1997


37

Medical care and the economy

• Spending on medical care stimulates the

economy (to a point)

– South Africa example

• However, society must value the output

produced by medical care

Behavior and health

• Unsafe sexual behavior

• Poor diet - too many cheeseburgers and chicken wings

• Lack of exercise

• Do not wear seat belts

• Crazy driving, especially in Texas!

Health care vs. education

From Kindig, 1997

Environment and health

• 30,000 cancer deaths a year due to environmental or occupational exposure

• 230,000 kids have high blood lead levels

• Air pollution causes or contributes to asthma

Heredity and health

• Strong link between genetics and disease– 5% of persons have a genetic disease

which requires treatment before age 25 (Kindig)

– One-third of infant mortality due to genetic problems


42

Environment/Genetic Interaction

• When persons change their environment, there

risk of disease changes (Marmot)

• Incidence rates of coronary heart disease are

highest among Japanese men living in U.S.

mainland, followed by Hawaii, and then Japan

• Opposite true for stroke


43

Environment/Genetic Interaction

• Genetics and environment interact

• Smoking causes lung cancer, but not all

smokers die of lung cancer (there must be a

genetic factor)


44

Social factors in early life

• Biological processes affected by social factors

– Before birth: Maternal nutrients, smoking, affect

fetal development

– During infancy: malnutrition affects bodily growth

as well as cognitive functioning (and subsequently,

educational attainment)


45

Social support and social cohesion

• Social networks: number and frequency of social

contacts

• Social support: quality and type

– Emotional (Informational and self-appraisal)

– Instrumental or practical

– Negative interaction (close relationships can have

negative aspects)


46

Social support, morbidity, and mortality

• Alameda County Study

– Index based on marital status, no. contracts with friends and

relatives, and church and group membership

– Persons with low scores had 9-year mortality rates 1.9 to 3

times greater than those with high scores

– Results have been replicated in U.S. and Europe

• Lower social integration assoc. with higher likelihood

of MIS and stroke


47

Social support and social cohesion

• Effects on health

– Direct effect hypothesis: support leads to positive

health

• E.g. encouraging exercise, healthy behaviors

– Buffering effect hypothesis: Social support mediates

the effects of stressors on health

• E.g. emotional help may enable individual to deal with stressor


48

Social support and hormonal pathways

• Stress may initiate the secretion of adrenaline &

nonradrenaline

• Cyclical physiological responses can lead to illness

• High levels of social support associated with lower

heart rate, lower blood pressure, and lower cortisol,

adrenaline, and noradrenaline levels

(from Marmot and Wilkinson)


49

Social class and health

• Whitehall study

– Study of mortality rates among clerical,

professional/executive, and administrative

personnel in UK

– Clerical personnel had highest mortality rates

– Professional/executive personnel 2nd highest


50

Family factors and child health

• Socioeconomic status related to child growth

• Emotional family problems, such as divorce and

separation, negatively related educational attainment

• Mediated by an interest in the child

• Neglected, abused kids at higher risk for criminal

activity


51

Family factors and child health

• Socioeconomic status related to child growth

• Emotional family problems, such as divorce and

separation, negatively related educational attainment

• Mediated by an interest in the child

• Neglected, abused kids at higher risk for criminal

activity


52

Diet and disease

• Undernutrition

– E.g. Iodine deficiency

– Risk of diarrhea (most common cause of death among

children in the world) associated with breast feeding

• Overnutrition

– E.g. cardiovascular disease, cerebrovascular disease, cancer,

high blood pressure, overweight and obesity, dental caries

Where should we go from here?

• Most of today’s health problems could be prevented through behavioral modification

• We shouldn’t blame the medical system, but also shouldn’t spend as much on medical care

Where should we go from here?

• Should consider shifting resources from acute medical care to…– public health education, acute care for mental illness,

and geriatric care

• Need to critically evaluate all types of medical care services and procedures– Should discontinue unnecessary procedures, like

tonsillectomies and routine check-ups

McKinlay and Marceau, AJPH, 2000

health care organization introduction to health care organization - for medical students - ty...

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